Double stapled ileal pouch anal anastomosis (DS-IPAA) for mucosal ulcerative colitis (MUC): is there a correlation between the tissue type in the circular stapler donuts and in follow-up biopsy?

PURPOSE: This study aims to assess the correlation between the tissue types found in the circular stapler donut at the time of initial double-stapled ileal pouch-anal anastomosis (DS-IPAA) and during subsequent periodic routine random biopsy. Secondarily, we sought to assess the risk of dysplasia, carcinoma or mucosal ulcerative colitis (MUC) recurrence in the retained mucosa. METHODS: The pathology reports of 91 patients (48 males, 43 females) who were operated upon for MUC from September 1988 to June 1997 and were reviewed and had two follow up visits for biopsy. The histological features of the distal donuts and biopsies of retained mucosa obtained at yearly interval follow-up were assessed in order to determine the epithelial tissue type (columnar, transitional and squamous), inflammation, recurrence of MUC and presence of dysplasia or malignancy. RESULTS: Median age at surgery was 43 (range 15-71) years and duration of MUC was 9.6 (range 0.3-42) years prior to surgery. The anastomosis was performed at a median height of 1.0 (range 0-2.5) cm cephalad to the dentate line and biopsy follow-up was undertaken at median 34 (range 2-110) months after DS-IPAA. The distal donuts were analysed in all cases, as were 305 follow-up biopsies (median 3.4; range 1-7 per patient). Although columnar epithelium (CE) was found in 62 (68%) donuts, it was absent on follow-up biopsy in 16 (26%) of these patients. Conversely, although no CE was identified in 29 (32%) donuts, it was identified in 11 (38%) of these patients during follow-up biopsy. CE in the donut was a significant predictor of CE in subsequent biopsies (P = 0.0012). The histological features consistent with MUC were seen in the biopsies from the retained mucosa in 15 (16%) patients from 0.3 to 7.6 years after DS-IPAA. While eight (9%) patients exhibited dysplasia or adenocarcinoma in the excised colon or rectum, none of the patients had either dysplastic changes or carcinoma within the retained mucosal biopsies. CONCLUSION: The correlation between CE in the circular stapler donut and at follow-up biopsy was high. However since CE developed in some patients in whom no CE was present in the distal donuts, regardless of the epithelial tissue type finding at the time of DS-IPAA, periodic follow-up biopsy should be obtained.

Colonic J-pouch function in rectal cancer patients: impact of adjuvant chemoradiotherapy.

PURPOSE: The colonic J-pouch technique of reconstruction optimizes functional outcome after proctectomy with coloanal anastomosis. However, the impact of adjuvant chemoradiation therapy on pouch function in rectal cancer patients has not been investigated. METHODS: From January 1994 to December 1999, 74 patients with midrectal or low rectal tumors (less than 10 cm from the anal verge) underwent a proctectomy with coloanal anastomosis with colonic J-pouch reconstruction. Chemoradiation was offered in patients with Stage II and III disease. Radiation therapy was administered using a four-field technique including the anal canal, for a total dose of 50.4 Gy (1.8 Gy/fraction/day). Fifteen patients (20 percent) died with metastatic disease, five (6.8 percent) died of other causes without evidence of recurrence, and five (6.8 percent) were lost to follow-up. In addition, two patients had local recurrence (2.7 percent) at the time of follow-up. Forty-five of 47 eligible patients (96 percent) responded to a questionnaire designed to evaluate specifically the degree of continence and pouch evacuation. RESULTS: The mean age of patients was 68.9 (range, 42-88) years and the mean duration of follow-up was 28.8 (range, 1-69) months. There were 28 patients in the surgery alone group and 17 patients who received either preoperative (13) or postoperative (4) adjuvant chemoradiation therapy. Patients in the surgery alone group had a significantly better degree of continence (mean +/- standard deviation continence score: 18.1 +/- 2.9 vs. 13.3 +/- 4.1, P < 0.001) and were less likely to experience evacuatory problems (mean +/- standard deviation evacuation score: 21.3 +/- 3.7 vs. 16.4 +/- 3.5, P < 0.001). Use of a pad was more frequent in the chemoradiation therapy than in the surgery alone group (53 vs. 18 percent, P = 0.02). The incidence after functional disorders was also more frequent in the irradiated group of patients: incontinence to gas (76 vs. 43 percent, P = 0.03), to liquid stool (64 vs. 25 percent, P = 0.01), and to solid stool (47 vs. 11 percent, P = 0.01). Moreover, irradiated patients reported more frequent pouch-related specific problems, such as clustering (82 vs. 32 percent, P = 0.001), and sensation of incomplete evacuation (82 vs. 32 percent, P = 0.001). Finally, regression analysis demonstrated that radiation-induced sphincter dysfunction was progressive over time. CONCLUSIONS: Both preoperative and postoperative chemoradiation therapy adversely affects continence and evacuation in patients with colonic J-pouch. Because radiation-induced damage to the normal tissues is known to be cumulative over time, long-term progressive dysfunction of the anal sphincter and neorectum are causes of concern. Consideration should be given to excluding the anal canal from the field of irradiation in patients with Stage II and III rectal cancer, whenever a sphincter-preserving procedure is planned.

Functional outcome of stapled ileal pouch-anal canal anastomosis versus handsewn pouch-anal anastomosis.

This study was conducted to determine whether stapled ileal pouch-anal canal anastomosis (IACA) preserving the anal transitional zone (ATZ) or hand-sewn ileal pouch-anal anastomosis with mucosectomy (IPAA) is more beneficial in achieving disease eradication and better postoperative function. IACA was performed in 10 patients with ulcerative colitis (UC) and 10 patients with familial adenomatous polyposis (FAP), 15 of whom were examined proctoscopically. IPAA was performed in 4 patients with UC and 8 patients with FAP. The mean maximum resting pressure (MRP) was 55 mmHg in the IACA group and 34 mmHg in the IPAA group (P < 0.01). The anorectal inhibitory reflex was positive in 18 patients (90%) from the IACA group and 5 (42%) from the IPAA group (P < 0.05). The pre- and postoperative MRPs were 61 mmHg and 55 mmHg, respectively, in the IACA group vs 63 mmHg and 34 mmHg, respectively, in the IPAA group (P < 0.01). Whereas 16 (80%) of the 20 IACA patients could discriminate feces from gas, only 4 (33%) of the 12 IPAA patients could (P < 0.05). The mean observation period was 2.3 years, the mean length of the columnar cuff was 2.8 cm, and no case of dysplasia or adenoma was seen. Postoperative function is more favorable following IACA than following IPAA, both physiologically and symptomatically. However, long-term surveillance of the residual mucosa is necessary before making a final recommendation.

A case of classical carcinoid tumor of the gallbladder: review of the Japanese published works.

A 58 year-old man was admitted to Kimitsu Chuo Hospital complaining of epigastralgia. Abdominal ultrasound and computed tomography revealed a polypoid lesion at the neck of the gallbladder. Given the pre-operative diagnosis of gallbladder carcinoma, we resected the gallbladder along with the extrahepatic bile duct. There was a papillary tumor (25 x 16 mm) at the neck of the gallbladder. Histopathological examinations showed a subserosal nodular proliferation of uniform small tumor cells. Grimelius staining was slightly positive and Fontana-Masson staining was negative. Most of the tumor cells stained positively for chromogranin A and neuron-specific enolase (NSE), and some of the tumor cells were positive for pancreatic polypeptide. The presence of neurosecretory intracytoplasmic granules was proven ultrastructurally. It was diagnosed as a classical carcinoid tumor of the gallbladder. We reviewed the Japanese reported cases and discussed the difference in clinicopathological findings between classical and atypical carcinoid tumors of the gallbladder. Classical carcinoids of the gallbladder have neither a metastatic nor invasive character, and an extremely favorable prognosis compared with atypical carcinoids. The difference in character between classical and atypical carcinoids of the gallbladder is thought to be derived from their histogenetic origin.

[The results of p53 immunostaining in colorectal adenomas, early cancers, advanced cancers and their hepatic metastasis].

Overexpression of the p53 protein was analyzed in colorectal adenomas, early cancers, advanced cancers and their hepatic metastasis by immunostaining using monoclonal antibody (DO-7). Positive staining for p53 was detected in 8 (22.9%) of 35 adenomas, 19 (82.6%) of 22 early cancers, and 59 (63.2%) of 95 advanced cancers. In adenomas, p53 immunoreactivity for severe dysplasia was higher than that for mild or moderate dysplasia (3/9.33.3% vs 2/16.12.5% or 3/10.33.3%), we found almost the same p53 immunoreactivity both in early cancers in adenoma (7/8.87.5%) and "de novo" cancers without an adenoma component (12/14. 85.7%). In 95 of advanced cancers, we found p53 positive cells in 33 (76.7%) of 43 cases with hepatic metastasis, against 26 (50.0%) of 52 cases without hepatic metastasis and surviving more than 5 years from the colorectal cancer resection. The former group had a significantly higher incidence of p53 overexpression (p < 0.05). In the 33 above mentioned cases, both primary and liver metastatic lesions were p53 positive, and the others were negative in both of them. In this series, it was suggested that p53 had important roles in the colorectal adenoma-carcinoma sequence from adenoma to advanced cancer and its metastatic potential, as well as in "de nove" carcinoma.

[Immunohistochemical distribution of p53 and Ki-67 in 2 cases of colorectal carcinoma occurring in ulcerative colitis].

We studied immunohistochemically the distribution of p53 overexpression and Ki-67 as a marker of cell proliferation, in 2 cases of advanced colorectal carcinomas occurring in UC, in comparison with histopathological features such as carcinoma and dysplasia. One is a case of 4 independent colorectal carcinomas surrounded by widespread dysplasia, and the other is a case of solitary rectal carcinoma. In these 2 cases, formalin-fixed paraffin-embedded tissues covering all of the resected specimens were examined for p53 and Ki-67 immunoreactivity using microwaving technique. p53 was negative in normal mucosa and inflammative mucosa without dysplasia. p53 was strongly positive in cancerous lesions except one lesion, and various degrees of dysplasia surrounding these lesions also showed p53 positive. The numbers of p53 and Ki-67 positive cells were higher in severe dysplasia than in mild dysplasia. Some areas of the dysplastic mucosa histologically represented "hyperplastic pattern of villous feature." In these areas p53 positive cells were aggregated in the basal part of the villous crypt, and the number of Ki-67 positive cells per gland was larger than in normal gland. Our examination covering the whole mucosa revealed: 1) p53 and Ki-67 are useful diagnostic markers for grading the degree of dysplasia. 2) Positivity of immunoreactive p53 in dysplasia seems to be consistent with that in cancers occurring in the surrounding dysplastic area in most of our cases.

[Experimental study of right ventricular assists for severe right ventricular failure].

The efficacy of two right ventricular assist systems for severe right ventricular failure caused by multiple ligation of the right coronary artery and right ventricular free wall with ventricular septal infarction was studied in 20 adult dogs in order to determine a better assist system in terms of hemodynamics and ventricular function. Two types of assist systems, a right ventricular bypass (RVAS) and an RVAS with intraaortic balloon pumping (IABP) were applied. The assist flow changed the preoperative aortic blood flow by 20%, 40%, 60% and 80%, respectively. The RVAS decreased the preload of RV and resulted in an effective RV assist. But RVAS did not effectively improve the aortic pressure (AP), left atrial pressure (LAP), aortic flow (AF), coronary sinus flow (CSF), left ventricular end diastolic pressure (LVEDP), LV stroke work (LVSW), or the endocardial viability ratio (EVR). On the other hand, RVAS with IABP significantly improves AP, LAP, AF, CSF, LVEDP, LVSW, and EVR as compared with the data of RVAS only. The optimal assist flow during RVAS with IABP might be 40-60% of the preoperative aortic blood flow.

[A case of partial anomalous pulmonary venous return to inferior vena cava and left atrium (Scimitar syndrome)].

Scimitar syndrome is relatively uncommon syndrome. A 14-year-old female referred to our hospital for abnormal shadow of chest fluoroscopic examination. She had no symptom except cough due to bronchial asthma. Chest X-ray film showed Scimitar sign. Cardiac catheterization revealed 30% left to right shunt without atrial septal defect. Pulmonary angiography showed anomalous pulmonary vein was drained to inferior vena cava and left atrium. Surgical correction was attempted monitoring the pulmonary arterial pressure. Anomalous pulmonary vein and systemic arteries were ligated and divided at the level of diaphragm. Postoperative course was smooth. We have found 4 similar operated cases previously reported in the world.